Systematic desensitization is one form of exposure therapy used in cognitive behavioral therapy (CBT). Systematic desensitization aims to reduce anxiety, stress, and avoidance by gradually exposing a person to the source of their discomfort in a thoughtfully planned way. With the inclusion of relaxation techniques, systematic desensitization helps to relieve symptoms connected to various forms of anxiety and anxiety-related conditions.
What Is Systematic Desensitization?
Systematic desensitization is a version of exposure therapy used to help people address various mental health concerns. In this treatment, an individual works with a therapist to learn relaxation techniques and plan a methodical series of exposures to anxiety-provoking stimuli.1 When people face their fears, stress increases in the short-term, but systematic desensitization is based on the idea that uncomfortable reactions will dissipate with long-term exposure.
Like other forms of exposure therapy, systematic desensitization falls under the umbrella of cognitive behavioral therapy (CBT), a branch of psychotherapy that sees value and connection in a person’s thoughts, feelings, and behaviors. Exposure therapies are based on the idea that many fears, worries, and stressors emerge from distorted thinking patterns and avoidant behaviors.
Shifting from avoidance to exposure demonstrates the following:1
- Avoidance and escape are not the only ways to manage stress and fear
- Repeated exposures to a stressor will reduce its impact
- The awful imagery outcomes of their stressor will not happen from exposure
Systematic desensitization employs multiple processes to create these changes including:2,3
- Emotional processing: With the exposure of systematic desensitization, the person begins to develop more realistic expectations and beliefs about the anxiety-causing stimuli. Instead of reacting in unpredictable or irrational ways, their response will be more moderate and appropriate.
- Extinction: In many cases, fears become inappropriately reinforced through situations and avoidance. These distorted associations will begin to break down and become extinct when the stimuli does not cause the feared effect.
- Habituation: After repeated exposures to a trigger, the trigger loses its power because of the body’s desire to maintain equilibrium. Feeling cold after jumping into a swimming pool slowly fades as the body becomes accustomed to the temperature. The temperature doesn’t change, only the perception of the water changes.
- Self-efficacy: Avoidance makes people feel like their fears are more powerful than they are, but with exposure through systematic desensitization, they learn that they can effectively manage their reactions to triggers. This experience provides a level of control that helps accomplish and maintain change.
The Process of Systematic Desensitization
The process of systematic desensitization will never look alike for two people because therapists work to study and understand how each person’s trigger affects them. In general, though, systematic desensitization follows a routine progression that involves defining the fear, rating situations that trigger different fear ratings, exposure, reviewing progress, and repeating the exposure/ review process until the ultimate fear is completed.4
Psychoeducation & Relaxation
Even though the concept of “facing one’s fears” is commonly understood, some clients may struggle to understand how exposure to a stressor will result in less stress in the future. The mental health professional will thoroughly explain the process and receive full consent from the client to begin treatment. Along with psychoeducation, relaxation techniques are an essential element of systematic desensitization. They aim to lower the body’s overall reaction to the trigger. This way, the person will be more likely to continue on with treatment and accomplish their goals.
Establishing the Fear Hierarchy
A “fear hierarchy” is a list established between the therapist and client to describe and rate triggering stimuli. The list begins with the scariest, most challenging situation at the top to represent the level-ten item. Then, the discussion shifts to the lowest situation that would cause fear to represent the level-one stress.
Once the range is established, the therapist and client will brainstorm steps along the way that cover the entire spectrum of anxiety. Having many steps and exposures is necessary, so at least 15 separate items should be on the fear hierarchy. With too few, there are not enough opportunities for exposure.4
Complete Level-One Exposure
Systematic desensitization relies on completing the fear hierarchy in a step-by-step progression by starting with the scenario that will cause the least amount of stress before moving to level two. This exposure could occur during therapy session, or it could be assigned as homework for in between sessions.4
Ideally, the process happens in the office, so the therapist can model, shape, and guide the client’s experience by giving prompts and reinforcement. Due to practical issues, many exposures need to happen outside of session, too.
When the exposure takes place, the client will experience an expected increase in anxiety. They will utilize their relaxation techniques to calm their body and mind to remain engaged in the process while emotional, processing, extinction, habituation, and self-efficacy grow. Once the anxiety drops by at least 50% of its peak value, the exposure ends and is qualified as a success. The client then reflects or documents their experience to share with the therapist.
Review & Repeat
As long as the first exposure is successful, the client and therapist will meet to discuss the effects of exposure, track the symptoms, and the use of relaxation. Unless something transpired to make them rethink the hierarchy, the client will move on to the next exposure.
From here, a consistent pattern emerges with exposure, review, and repeat. This routine is where systematic desensitization gets its name. It is thoughtful, deliberate, and measured. Completing the exposures in this way creates the sense that each step of the hierarchy is only as challenging as the one before because the negative associations are breaking down.
Techniques Used In Systematic Desensitization
The techniques used in systematic desensitization are delineated based on the form of real or imagined exposures implemented to achieve results. Fortunately, there is good evidence to suggest the techniques all work well. Common techniques involved in systematic desensitization include in vivo, imagination, virtual reality, and interoceptive exposure.
In Vivo Exposure
In exposure therapy, in vivo exposure is a technique that incorporates the actual feared stimulus. So, if a person is afraid of spiders, there will be real spiders used during exposure. If the person is afraid of heights, treatment will involve tall buildings, bridges, and cliffs. In vivo is a wonderful option because it does not rely on the imagination or creativity of the therapist or client. It only requires access to the feared stimuli.1
Imaginal Exposure
During imaginal exposure, the therapist will prompt the client to imagine being in a situation or setting with their trigger. Through the use of guided imagery techniques, the therapist can encourage a more realistic and vivid mental picture, which helps to better recreate the fearful situation. Imagination exposure is a great option for triggers that are too dangerous or too uncommon to duplicate in an office or home setting.2
Virtual Reality Exposure
Technological advances are helping to bridge the gap between imaginal and in vivo exposure. Using VR headsets, body sensors, and haptic feedback, virtual reality exposure programs are able to reproduce the sights, sounds, and other sensations of the feared setting. Of course virtual reality exposures are not available for all triggers, but for people with a common fear, like flying, virtual reality exposure can reduce symptoms without the expense of buying a plane ticket.2
Virtual reality exposure is also helpful for situations that are too dangerous to replicate, like in the case of combat or life-threatening experiences linked to post-traumatic stress disorder (PTSD).5 Using established software programs, VR can transport the client to another place and time to receive exposure.
Interoceptive Exposure
Panic, stress, and anxiety produce a range of physiological consequences including rapid heart rate, increased respiration, and sweating. Interoceptive exposure aims to bring about these responses separate from their fearful trigger.2 By completing physical activities to induce these body changes, the client begins to break the connection between the stimulus and the response, which lowers the power and control of the trigger. This form of exposure emphasizes the point that much of anxiety is discomfort, not danger.
What Can Systematic Desensitization Help With?
When used alone or in conjunction with other forms of treatment, systematic desensitization can effectively treat the following mental health conditions:2
- Specific phobias, like fear of heights, flying, spiders, and enclosed spaces
- Panic disorder
- Social anxiety disorder (social phobia)
- Obsessive-compulsive disorder (OCD)
- Post-traumatic stress disorder (PTSD)
- Generalized anxiety disorder
Not only can systematic desensitization help with diagnosed mental health conditions, it can also assist with uncomfortable aspects of life that do not meet the threshold for a diagnosis. A professional who worries about speaking in public or a student that experiences some test-taking anxiety can utilize the principles of systematic desensitization to improve their skills and master challenging obstacles.
Systematic Desensitization Examples
Systematic desensitization will often follow a progression like the one outlined above with fear hierarchies and exposures, but the clients and therapists involved will also require creativity and a unique perspective to make the treatment tailored to one’s individual needs and experience. A more individualized process will result in better outcomes.
Specific Phobia: Fear of Heights
Sessions will begin with a combination of psychoeducation and relaxation training. Then, the therapist and client will work to create a fear hierarchy involving heights, starting with the most extreme trigger before moving to the lowest possible trigger and then filling in the gaps.
Using in vivo exposure, the therapist will lead the client through the progression of heights while offering reminders about relaxation skills and cognitive thinking patterns to help the experience. Someone riding on an escalator as an exposure will track their anxious response, usually on a ten or 100-point scale. If they begin at an 80 out of 100, they will continue riding the escalator until their anxiety falls below 40. At that point, the exposure is complete.
From there, the client can process and review the exposure with the therapist. Some people will complete multiple exposures in one day, while others will spread them out over time, depending on the physical and emotional toll exposures take.
Social Anxiety Disorder
Social anxiety disorders involve a severe and debilitating level of stress, fear, and worry when faced with other people or social interactions. This condition can significantly impair a person’s ability to work, go to school, and have meaningful relationships, but systematic desensitization can resolve these fears.6
With early sessions focusing on education, relaxation, cognitive skills, and a fear hierarchy, treatment may utilize a combination of in vivo and imaginal exposures. Perhaps, anxiety is so strong that imagined contact with others is enough to create a strong anxious response.
Good fear hierarchies aim to have the client complete exposures beyond what they would typically have to do. For example, someone with social phobia could plan to speak in front of a group of 100 people, even though there would be no reason to do this ordinarily, because it will create higher levels of habituation and self-efficacy that will generalize to future challenges.4
OCD With Fear of Contamination
OCD presents in many forms, but a person who is obsessed with cleanliness and fears contamination and compulses by washing their hands could respond quite well to systematic desensitization. In this case, the fear hierarchy will include a list of things the person finds “dirty, diseased, or gross.”
The exposures may begin by touching something like a doorknob or button on an elevator before progressing towards toilet seats and raw chicken. Again, overshooting the normal expectation could result with the client taking a trip to a sewage treatment plant or touching animal droppings, even though they would not normally encounter either.
Touching these items will trigger the desired level of stress and anxiety, but the response always diminishes in a predictable way when they stick to the plan. Since the hand washing compulsion is such an important part of this form of OCD, the client and therapist will have to make arrangements for limited and controlled handwashing.
How to Find a Therapist Who Practices Systematic Desensitization
Because systematic desensitization is a widely used treatment option, finding a therapist who is experienced with the practice should be relatively easy. While there may not be many practitioners who would claim they “specialize” in systematic desensitization, many are competent in the practice. To search for an expert clinician in a specific area, consider using an online directory.
Who Is Able to Provide Systematic Desensitization?
Systematic desensitization is a complex variation of CBT, but since it pulls from so many fundamentals of therapy, a provider does not need additional training or certifications to offer the treatment. Of course, the therapist should have the appropriate education and experience, as well as access to supervision to help guide the process.
Cost of Systematic Desensitization & Does Insurance Typically Cover it?
For a person with a diagnosed mental health condition, insurance companies will cover the treatment as they would any other evidence-based intervention. People interested in systematic desensitization should be sure to check with their insurance company to identify any deductibles, copays, and other out-of-pocket expenses they can expect.
Without insurance, systematic desensitization usually costs between $50 and $150 per session, which may be a cheaper option than medications to treat the same conditions. One study found exposure therapy to cost about $1,600 less than medication therapy when used for PTSD treatment.7
10 Key Questions to Ask a Therapist When Considering Systematic Desensitization
Gaining as much information as possible from the treatment provider before initiating any therapy can serve as a guide to the coming sessions. This information can also establish expectations that are fair and realistic. Let answers to your questions either build trust and confidence in the therapist or provide a sign that another provider may be a better option.
Here are ten key questions to ask a therapist using systematic desensitization:
- Is systematic desensitization an appropriate treatment for me?
- When will exposures take place? During session, or will I be expected to engage in exposures in between sessions?
- How long will my treatment last?
- Can we speed up or slow down the process?
- How long have you been performing systematic desensitization?
- Do you receive consultation or supervision from an expert?
- Should I use in vivo, imagined, virtual reality, or a combination of exposure techniques to feel better?
- Will the anxiety return after treatment ends?
- What if an exposure is too scary and I need to stop?
- Will you use other types of treatment with the systematic desensitization?
What to Expect at Your First Appointment
Depending on the provider and your needs, the first session of systematic desensitization therapy could represent the entire course of treatment as you and your therapist quickly work to learn relaxation, build a hierarchy, and move through exposures at a rapid pace. Some exposure treatments are conducted during one long session, instead of several one-hour-long sessions.1
In most situations, though, the first session will focus on assessment and education. The therapist will gather information to ensure your symptoms can be well-treated with systematic desensitization, and then, you will devise a treatment plan with goals and timeframes.
Is Systematic Desensitization Effective?
Systematic desensitization is consistent, effective, and backed by years of evidence. It is the primary treatment for phobias, social anxiety, and other anxiety disorders, and is also highly effective for PTSD and OCD.
Statistics & Facts
Research and studies on systematic desensitization and other exposure therapies find:3
- 90% of people who experience one session of in vivo exposure report less fear, less avoidance, and less overall impairment with results lasting for years
- 65% of people who used exposure therapy for a specific phobia noted their disorder being eliminated after one session
- For people with OCD, 86% reported lower symptoms with exposure compared to only 48% of those who received medication
- Exposure therapy produces results that last longer after treatment ends compared to medication-only treatment and treatment using exposure and medication
Risks of Systematic Desensitization
The primary risk of systematic desensitization comes from inexperienced therapists or frightened clients who do not allow the full desensitization to occur. After exposure, if the anxious response is not allowed to reduce to less than 50%, the fear becomes sensitized, not desensitized, which means the person will have stronger reactions in the future.4
In people with PTSD, systematic desensitization risks creating a retraumatizing effect. This increase in symptoms could be short-term or long-term, so the therapist and client must plan and prepare for the chance of this occurring.8
Criticisms of Systematic Desensitization
Criticism of systematic desensitization comes from proponents of other exposure therapies. For example, some may believe that the addition of relaxation actually slows the progress by lowering the full extent of the fear response.1
These critics believe that by diminishing the stress, the person is not allowed to build the habituation that they would from other exposures without relaxation.
Though this criticism is valid, a client may prefer the idea of lower anxious responses and may be more inclined to begin and follow through with treatment. Plus, relaxation techniques are helpful tools for many situations and can be used in and out of systematic desensitization.
How Is Systematic Desensitization Different Than Other Therapy Techniques?
Systematic desensitization shares many similarities to exposure therapy, general CBT, and other forms of therapy that involve some level of real or imagined exposure. By having so many alike features, it becomes challenging to distinguish systematic desensitizations from other therapy techniques.
Systematic Desensitization vs. Exposure Therapy
Systematic desensitization is not a treatment separate from exposure therapy. Instead, systematic desensitization is a form of exposure therapy. There are many ways to complete a course of exposure therapy, and anytime the focus is on gradual and methodical exposure with the incorporation of relaxation, the therapy is systematic desensitization.
Systematic Desensitization vs. EMDR
Systematic desensitization and eye movement desensitization and reprocessing (EMDR) are both available treatments for PTSD and other anxious disorders. Both encourage the person to re-experience the trauma through exposure to lessen its impact.
The major difference with EMDR is the importance of directed eye movements, sounds, touches, and other types of bilateral stimulation. These help to reprocess the trauma, so the client is no longer as affected by the unwanted experiences.9
These aspects are absent from systematic desensitization.
Systematic Desensitization vs. Exposure & Response Prevention
Exposure and response prevention (ERP) is the first-line psychotherapy option for OCD, and though it incorporates many elements of exposure therapy, it uses a customized direction to produce better outcomes for people with obsessions and compulsions. ERP uses the same exposure aspects as systematic desensitization, but with the focus on response prevention, it ensures that people do not engage in the compulsive behavior as a way to reduce their mental discomfort.10 Breaking this association is challenging but essential.
History of Systematic Desensitization
Psychology in the first half of the 20th century was ruled by psychoanalysts who believed unconscious thoughts and desires fueled a person’s feelings and actions and building insight to these issues could create change. When Joseph Wolpe proposed a person could change their feelings by changing their behaviors in the 1950s, it seemed like a foreign concept to the psychological establishment.4
Certainly, the concept of facing your fears is nothing new, but Wolpe was the first mental health professional to discover and document how exposing oneself to the source of their fears in a gradual and progressive way can result in symptom relief. Today, it fits in perfectly with many concepts of CBT and psychology as a whole.
Over the years since Wolpe’s work in South Africa, many practitioners and researchers have explored ways to make exposure more effective. With advances linked to virtual reality, systematic desensitization is being used in ways Wolpe could have never imagined.
